The MPS has worked with other parity advocates to communicate parity enforcement concerns to the Maryland Insurance Administration (MIA). This informal group of advocates met with MIA officials on November 17, 2017 to discuss the results of its second market conduct exam regarding insurer compliance with the Mental Health Parity and Addiction Equity Act. The MIA has completed its review of United Healthcare’s plans, which had been pending following release of the other second market conduct survey results. It is not clear when the MIA will release the United results. The MIA is still working on its review of CareFirst plans and on one outstanding issue identified in its response to our letter.
Referrals to Specialists
On October 31, 2017 MIA issued a bulletin regarding information that must be reported as a result of HB 1318, enacted in 2016. Carriers must now include in their procedures available to insureds via the carrier’s online network directory:
- steps the carrier requires of a member to request a referral
- carrier’s timeline for decisions; and
- carrier’s grievance procedures for denials. [click for more details]
Report on the Health Care Appeals & Grievance Law
On December 14, 2017, the Maryland Insurance Administration (MIA) released its annual report on adverse decisions and grievance decisions under Maryland law. Although the law applied to about 43% of the population with insured health benefits when it was enacted, by 2016 the percentage had dwindled to just 20%. The Appeals and Grievance process begins when a carrier renders an “adverse decision” that care is not medically necessary. If the patient (or his/her representative) protests this decision, it is called a “grievance.” If the carrier stands by the original decision, the patient can file a “complaint” with MIA.
Among the findings in the report are:
- Adverse decisions for mental health services increased by 70% from 2013 to 2016 (687 in 2013 and 1,169 in 2016).
- Despite the rise in adverse decisions, the number of grievances for mental health services decreased by 43% over the same period (238 in 2013 to 136 in 2016).
- Adverse decisions for mental health services were highest at Aetna, followed by CareFirst.
- For complaints filed with MIA, the carrier decision was upheld by MIA 60% of the time for partial hospitalization for mental health/substance use, 70% of the time for inpatient and 50% of the time for outpatient.